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Lou Agosta

Greetings and welcome to my blog focusing on reengineering healthcare using information technology. The commitment is to provide an engaging mixture of brainstorming, blue sky speculation and business intelligence vision with real world experiences – including those reported by you, the reader-participant – about what works and what doesn't in using healthcare information technology (HIT) to optimize consumer, provider and payer processes in healthcare. Keeping in mind that sometimes a scalpel, not a hammer, is the tool of choice, the approach is to be a stand for new possibilities in the face of entrenched mediocrity, to do so without tilting windmills and to follow the line of least resistance to getting the job done – a healthcare system that works for us all. So let me invite you to HIT me with your best shot at

About the author >

Lou Agosta is an independent industry analyst, specializing in data warehousing, data mining and data quality. A former industry analyst at Giga Information Group, Agosta has published extensively on industry trends in data warehousing, business and information technology. He is currently focusing on the challenge of transforming America’s healthcare system using information technology (HIT). He can be reached at

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September 2011 Archives

The answer is clinical data warehousing, decision support, and analytics. What's the question? Wellpoint (one of the leading Blue Cross branded health insurance companies) is reportedly contracting to use IBM's computing grand challenge system nicknamed "Watson" (after IBM's founder) to address a list of clinical issues in medical diagnosis, treatment, and (potentially) cost. In the spirit of Jeopardy!, the question is will it advance in the direction of enabling comparative effectiveness research (CER) and pay for performance (P4P) while enhancing the quality of medical outcomes? Healthcare consumers tend to get a tad nervous when they suspect that insurance companies are going to deploy a new computer system as part of the physician payment approval process, nor (let us be clear) has anyone actually said that will happen in this case.

The diagnosis of a disease is part science, part intuition and artistry. The medical model trains doctors and healthcare specialists using an apprentice system (in addition, of course, to long schooling and lab work). The hierarchical nature of disease diagnosis has long invited automation using computers and databases. Early expert medical systems such as MYCIN at Stanford or CADUCEUS at Carnegie-Mellon University were initially modest sized arrays of if-then rules or semantic networks that grew explosively in resource consumption, time-to-manage, and cost and complexity of usability. They were compared in terms of accuracy and speed with the results generated by real world physicians. The matter of accountability and error was left to be worked out later. Early results were such that automated diagnoses was as much work, slower, and not significantly better - though the automation would occasionally be surprisingly "out of the box" with something no one else had imagined. One lessons learned? Any computer system is better managed and deployed like an automated co-pilot rather than a primary locus of decision making or responsibility.

Work has been ongoing at universities and research labs over the decades and new results are starting to emerge based on orders of magnitude improvements in computing power, reduced storage costs, ease of administration, and usability enhancements. The case in point is IBM's Watson, which has been programmed to handle significant aspects of natural language processing, play jeopardy (it beat the humans), and, as they say in the corporate world, other duties as assigned.

Watson generates and prunes back hypotheses in a way that simulates what human beings do in formulating a differential diagnoses. However, the computer system does so in an explicit, verbose, and even clunky way using massive parallel processing whereas the human expert distills the result out of experience, years of training, and unconscious pattern matching. Watson requires about eight refrigerator size cabinets for its hardware. The human brain still occupies a space about the size of a shoe box.

Still, the accomplishment is substantial. An initial application being considered is having Watson scan the vast medical literature on treatments and procedures to match evidence-based outcomes to individual persons or cohorts with the disease in question. This is where Waton's strengths in natural language processing, formulating hypotheses, and pruning them back based on confidence level calculations - the same strengths that enabled it to win at Jeopardy - come into play. In addition, oncology is a key initial target area because of the complexity of the underlying disorder as well as the sheer number of individual variables. Be ready for some surprises as Watson percolates up innovative approaches to treatment that are expensive and do not necessarily satisfy anyone's cost containment algorithm. Meanwhile, there are literally a million new medical articles published each year, though only a tiny fraction of them are relevant to any particular case. M.D.s are human beings and have been unable to "know everything" there is to know about a specialty for at least thirty years. In short,  Watson just could be the optimal technology for finding that elusive needle in a haystack - and doing so cost effectively.

A medical differential diagnosis in medicine is a set of hypotheses that subsequently have to be first exploded, pruned, and finally combined based on confidence and prior probability to yield an answer. This corresponds to the so-called Deep Question and Answering Architecture implemented in Watson. Within five years, similar technologies will have been licensed and migrated to clinical decision support systems from standard EMR/EHR vendors.

While your clinical data warehouse may not be running 3,000 Power 750 cores and terabytes of self-contained data in a physical footprint about the size of eight refrigerators, some key lessons learned are available even for a modest implementation of clinical data warehousing decision support:

  • Position the clinical data warehouse as a physician's assistant (think: co-pilot) to answer questions, provide a "sanity check," and fill in the gaps created by explosively growing treatments.
  • Plan on significant data preparation (and attention to data quality) to get data down to the level of granularity required to make a differential diagnoses. ICD-10 (currently mandated for 10/2013 but likely to slip), will help a lot, but may still have gaps.
  • Plan on significant data preparation (and more attention to data quality) to get data down to the level of granularity required to make a meaningful financial decision about the effectiveness of a given treatment or procedure. Pricing and cost data is dynamic, changing over time. New treatments start out expensive and become less costly. Time series pricing data will be critical path. ICD-10 (currently mandated for 10/2013 but likely to slip) will help but will need to be augmented significantly into new pricing data structures and even then but may still have gaps.
  • Often there is no one right answer in medicine - it is called a "differential diagnosis" - prefer systems that show the differential (few of them today do, though reportedly Watson can be so configured) and trace the logic at a high level for medical review.
  • Continue to lobby for tort and liability reform as computers are made part of the health care team, even in an assistant role. Legal issues may delay, but will not stop implementation in the service of better quality care.
  • Look to natural language interfaces to make the computing system a part of the health care team, but be prepared to work with a print out to a screen till then.
  • Advanced clinical decision support, rare in the market at this time, is like a resident in psychiatry, in that it learns from its right and wrong answers using machine learning technologies as well as "hard coded" answers from a database of semantic network.
  • This will take "before Google (BG)" and "after Google (AG)" in medical training to a new level. Watson-like systems will be available on a smart phone or tablet to residents and attendings at the bedside.

Finally, for the curious, the cost of the hardware and customized software for some 3,000 Power 750 cores (commercially available "off the shelf"), terabytes of data and including time and effort of a development team of some 25 people with Ph.D.s working for four years (the later being the real expense), my back of the envelope pricing (after all this is a blog post!) weighs in at least in the ball park of $100 million. This is probably low, but I am embarrassed to price it higher. This does not include the cost of preparing the videos and marketing. One final thought. The four year development time of this project is about the length of time to train a psychiatrist in a standard residency program.


  1. "Wellpoint's New Hire. What is Watson?" The Wall Street Journal. September 13, 2011.

  2. IBM: "The Science Behind and Answer":


Posted September 14, 2011 4:06 PM
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